VP Provider Manual 2020 - Virginia Premier
Provider Manual2020Corporate Office600 East Broad Street. Suite 400Richmond, VA 23219Tidewater Office825 Greenbrier Circle, Suite 200Chesapeake, VA 23320Roanoke Office5060 Valley ViewBoulevard NW Roanoke, VA 23012Bristol Office105 Village CircleBristol, VA 24209DMAS 0121-PM-300103
Virginia PremierPO Box 5307Richmond, VA 232201-800-727-7536 (TTY:711)VirginiaPremier.comHours of OperationMonday – Friday,8:00 am - 8:00 pm, ESTVirginia Premier is a registered service mark of Virginia PremierHealth Plan, Inc. All other trademarks/service marks remain theproperty of their respective companies. All rights reserved.
Dear Provider:Thank you for becoming a participating provider with Virginia Premier. Attached is the 2020 VirginiaPremier Provider Manual with the information you need to answer questions related to preauthorizations, claims, appeals and grievances, credentialing / re-credentialing, quality and utilizationmanagement programs, Assertive Community Treatment (ACT), plans of care (ICP), health riskassessments (HRAs) and compliance.To request a hard copy of the manual or to receive additional provider training, please contact yourProvider Services Representative. Updates and revisions to the provider manual are communicatedthrough inserts, website announcements and provider mailings, and are considered part of the NetworkProvider Agreement. Should you have questions concerning the manual, please contact your ProviderServices Representative at the numbers listed below:Central / NorthernVirginia800-727-7536press 6Roanoke888-338-4579press 4Tidewater800-828-7989press 6Thank you,Network Development Department
TABLE OFCONTENTSPage 2
INTRODUCTION AND WELCOME . 10OUR MISSION . 10OUR VISION . 10HOW TO REACH US . 11Interpreter Services . 12COMMONWEALTH COORDINATED CARE PLUS (CCC PLUS). 12WHO ARE CCC MEM BERS . 13VIRGINIA PREM IER SERVICE REGIONS . 14Transportation Services . 16Introduction .16Eligibility Verification . 16Submission Standards . 16CMS-1500 Required Fields. 16ID CARDS AND ELIGIBILITY . 17New Member Information. 17Eligibility Verification. 17Member Identification Card . 17ID CARD SAMPLES . 18Virginia Premier Elite Plus. 18Virginia Premier Elite Family . 19Virginia Premier Elite Individual . 20Co-payments and Co-insurance. 21Enrollment Broker. 21PRIMARY CARE PHY SICIANS . 21Role of the Primary Care Physician . 21Availability . 21Nurse Advice Line. 22PCP Assignment. 22Member Panels. 22Example of Member Panel . 23Member / Provider Incompatibility . 23At Member’s Request. 23At the PCP’s Request. 23Change in Member Status. 24Immunizations . 24Page 3
UTILIZATION MANAGEMENT . 25Utilization Management Program. 25Authorizations. 25Out-of-Plan Authorizations. 31Pre-Authorization. 31Procedures Requiring Pre-Authorization . 31Authorization Decision Time Frames. 32Standard Authorization Decisions . 32Expedited Authorization Decisions. 33Utilization Management Staff Availability. 34Hospital Admissions: Elective Admissions. 34Admission / Concurrent Review. 35Care Management Services . 35Continuity of Care. 36Non-Certification / Denial of Certification . 36Inpatient Denials . 37Medical Necessity Appeals. 37Medical Necessity Criteria . 37Expedited Medical Necessity Appeal . 38Standard Medical Necessity Appeal . 38Emergency Services / Urgently Needed Care / ESRD Out of the Service Area. 39URGENT CARE . 39APPEALS . 39Expedited Medical Necessity Appeals. 39Standard Medical Necessity Appeals. 40EMERGENCY SERVICES. 40Gynecology and Obstetrical Services. 40Length of Stay Policy. 41Post-Delivery Services and Home Health. 41Gynecology Services: Direct Access Legislation. 42Family Planning . 42Sterilization Services. 42Healthy Heartbeats . 43WIC (Women, Infants and Children). 43Abortions. 44Infertility Services . 44Substance Use Services for Obstetric Patients . 44DIAGNOSTIC TESTING: LABORATORY SERVICES. 44CLIA Waived Tests . 44Page 4
Pre-Operative Lab Testing. 45Pathology Specimens. 45RADIOLOGY SERVICES AND GUIDELINES . 45Routine Radiological Studies . 45Outpatient Studies . 45Mammography Services . 46Preventive Services . 46MENTAL HEALTH SERVICES . 46CCC Plus . 47Medallion 4.0 . 47Psychological Testing . 47Inpatient Mental Health Services and Inpatient Substance Use Services . 48Temporary Detention Orders (TDO) . 48Free-Standing Psychiatric Facility Admissions – CCC Plus . 48Free-Standing Psychiatric Facility Admissions – Medallion 4.0. 49Registration of Services. 49Community Mental Health Services (CMHS) . 49Assertive Community Treatment (H0040)Behavioral Therapy H2033. 50Crisis Intervention (H0036) . 50Crisis Stabilization ( H2019) . 50Mental Health Skill-Building Services (Previously Mental Health Support Services) H0046Treatment . 51Mental Health Case Management (H0023) . 51Intensive In-Home Services for Children / Adolescents (H2012) . 52Mental Health Peer Support (H0025), Group Mental Health Peer Support (H0024) . 52Mental Health Intensive Outpatient Services (S9480)Partial Hospitalization Program( H0035) . 52Therapeutic Day Treatment Services for Children and Adolescents (H2016)Psychosocial Rehabilitation (H2017). 52Addiction Recovery Treatment Services (ARTS) CCC Plus and Medallion 4.0 ResidentialSubstance Use Treatment . 53ASAM Levels 3.1-3.7 (H2034, H0010, H0026). 53Opioid Treatment (H0020) . 53Substance Use Crisis Intervention (H0050) . 54Substance Use Day Treatment (H0047) ASAM Level. 2.5 . 54ART S Intensive Outpatient (H0015) ASAM Level 2.1. 54Outpatient Mental Health and Substance Use Services . 54Page 5
Peer Support Specialist T1012 ART S Individual; S9445 ARTS Group . 55MCO Billing Requirements for Preferred Office Based Opioid Treatment (OBOT) and OpioidTreatment Program (OTP) . 55LONG TERM SERVICES AND SUPPORTS. 56LTSS Providers . 57LTSS Authorizations . 57Elderly or Disabled with Consumer Direction Waiver (EDCD) Agency Directed Care (AD). 58Consumer Directed Care (CD) . 58Respite Services . 59Respite Care Follow-Up Services . 59Adult Day Health Care . 60Personal Emergency Response System (PERS) . 60Medication Monitoring . 60Early Intervention. 60Credentialing. 61EI Authorizations. 61Practice Changes: Psychological Testing. 61Technology-Assisted Waiver.61Intermediate or Custodial Nursing Facility Care . 62PHARM ACY SERVICES . 62Pharmacy Benefits . 62Pharmacy Network . 63Specialty Pharmacy Benefits . 63Non-Covered Drugs . 63Over-the-Count er Drugs.64IUD Distribution. 64Emergency Supply. 65Pharmacy Prior Authorization Guidelines . 65How to Contact Virginia Premier to request a Coverage Determination (Prior Authorization) . 66What if the request is denied? . 66An appeal can be requested either . 67Addiction and Recovery Treatment Services ( ARTS) . 67Patient Utilization Management and Safety (PUMS) Program. 68PUMS Program Goal. 68How Might PUMS Change a Member’s Care? . 68PUMS Member Rights . 68Page 6
ADDITIONAL ANCILLARY SERVICES . 69Physical and Occupational Therapy. 69Inpatient Rehab Services. 69Audiology and Speech Pathology Services. 69Vision Services . 69Vision Benefits (age 21 and over) . 70Dental Services. 70Home Health Services . 70Durable Medical Equipment (DME), Prosthetic Devices and Supplies . 70Nutrition Services. 71WIC (Women, Infants and Children). 71GENERAL LIMITATIONS AND EXCLUSIONS. 71Non-Covered Services . 71Carved-Out Services. 72Exclusions fromVirginia Premier Enrollment. 72Non-Participating Providers .73MEDICAL MANAGEM ENT PROGRAMS . 73Medical Outreach. 73Chronic Care Management. 74Care Management . 74Preventive Health and Wellness Programs . 75QUALITY PROGRAM . 76Quality Program Description . 76All practitioners are required to cooperate with Virginia Premier Quality Activities. . 76Quality Management Program Goals. 77Quality Management Program Objectives . 78Quality Management Program Functions. 78Accessibility Standards. 78Quality of Care Concerns. 78Quality of Care Issue . 78Quality of Care Event. 79Sentinel / Never-Prevent Event . 79Critical Incident. 80Serious Reportable Events . 80Procedures / Guidelines. 81Examples of the Virginia Premier Quality Program at Work Prenatal Care . 81Immunizations . 82Bereavement Program ( Medallion Only) . 82Page 7
Access to Care . 83Questions to Ask Your Physician . 8320 Tips to Prevent Medical Errors:. 83Medical Record-Keeping Policies. 84Office Site Reviews . 85Waiver Audit Site Visits (CCC Plus only) . 86Practitioners Golden Globe Award (PGA) . 86Culturally and Linguistically Appropriate Services. 86Goals of the Program . 87MODEL OF CARE (MOC) . 88Care Coordinator Overview . 88PROVIDER REIM BURSEM ENT AND CLAIMS. 89Claim Filing Guidelines. 89Paper Claim Submissions. 90Paper Claim Submissions. 90Coordination of Benefits (COB). 91Clean Claim Submission. 93Reimbursement . 93Primary Care Reimbursement. 93Primary Care Fee-for-Service . 93Encounter Reporting . 93Panel Report. 93Recoupment / Recovery Policy . 93Member Hold Harmless Policy . 93Denied Claims / Reconsiderations. 94FILING OF SPECIFIC CLAIM TYPES . 94Inpatient Rounding. 94Obstetric Services Reimbursement Schedule . 94OB Unbundled Method. 95Global OB Method.
Thank you for becoming a participating provider with Virginia Premier. Attached is the 2020 Virginia Premier Provider Manual with the information you need to answer questions related to pre- authorizations, claims, appeals and grievances,
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Native Shrubs and Woody Vines of Virginia Virginia Department of Forestry Identification Guide www.dof.virginia.gov This institution is an equal opportunity provider. Virginia Department of Forestry 900 Natural Resources Drive, Suite 800 Charlottesville, Virginia 22903 Phone: (434) 977-6555
EU Tracker Questions (GB) Total Well Total Badly DK NET Start of Fieldwork End of Fieldwork 2020 15/12/2020 16/12/2020 40 51 9-11 08/12/2020 09/12/2020 41 47 12-6 02/12/2020 03/12/2020 27 57 15-30 26/11/2020 27/11/2020 28 59 13-31 17/11/2020 18/11/2020 28 60 12-32 11/11/2020 12/11/2020 28 59 12-31 4/11/2020 05/11/2020 30 56 13-26 28/10/2020 29/10/2020 29 60 11-31
Provider Transition Plan (PTP) System PTP #AD-003910 Provider Information * Mandatory (required) fields below are marked with an asterisk. Legacy Provider ID * 0 New Provider ID * 0 Provider Name * Demonstration Provider Provide
Medicine provider, but they had insufficient data (i.e., the provider group does not have enough commercial health plan claims data to be evaluated, as required by the statistical requirements of the Provider Excellence Program; the provider group did not have enough quality data; or the provider group does not have enough cost-efficiency data). 3.
Provider ID: 1457472029 Provider Gender: Male Accepting New Patients: Yes Anthony Euser, DO 2801 Purcell St Brighton, CO 80601 303-659-7600 Adams County Provider ID: 1588634810 Provider Gender: Male Accepting New Patients: Yes John Fontenot, MD 1860 E Egbert St Brighton, CO 80601 303-659-4000 Adams County Provider ID: 1033373410 Provider Gender .
Demographic Change Form User Guide . Version 1.0 TX . 10/01/2020. 6. * Type of Provider (Note: Form needs to be completed and submitted for each applicable provider and/or group provider record ID#) A. Individual Provider is a provider who will not be employing another professional provider a.
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